Systemic lupus erythematosus. Controversies in management.

At the core of the controversy surrounding the management of systemic lupus erythematosus are the two issues of when to treat and what treatment to use. On the basis of a review of the recent medical literature, the following conclusions can be drawn: Patients with isolated serologic or histologic renal abnormalities in the absence of clinical disease activity probably should not be treated. Such abnormalities primarily serve to indicate the need for close follow-up and to heighten the physician's concern about the possible development of clinical symptoms. For those patients with systemic manifestations who require corticosteroids, a regimen of single daily doses is appropriate. The dose should be tapered as rapidly as the degree of symptomatic control allows; a switch to alternate-day therapy can be considered as symptoms become quiescent. Intravenous methylprednisolone therapy may be used for patients with very severe systemic disease, particularly acute nephritis. In addition, use of immunosuppressive agents should be considered for all patients with clinically serious renal disease.